Uninsured status may be more predictive of outcomes among the severely injured than minority race

AimWorse outcomes in trauma in the United States have been reported for both the uninsured and minority race. We sought to determine whether disparities would persist among severely injured patients treated at trauma centres where standard triage trauma protocols limit bias from health systems and providers.MethodsWe performed a retrospective analysis of the 2010–2012 National Sample Program from the National Trauma Databank, which is a nationally representative sample of trauma centre performance in the United States. The database was screened for adults ages 18–64 who had a known insurance status. Outcomes measured were in-hospital mortality and post-hospital care.ResultsThere were 739,149 injured patients included in the analysis. Twenty-eight percent were uninsured, and 34 percent were of minority race. In the adjusted analysis, uninsured status (OR 1.60, 1.29–1.98, p < 0.001) and black race (OR 1.24, 1.04–1.49, p = 0.019) were significant predictors of mortality. Only uninsured status was a significant negative predictor of post-hospital care (OR 0.43, 0.36–0.51, p < 0.001). As injury severity increased, only insurance status was a significant predictor of both increased mortality (OR 1.68, 1.29–2.19, p < 0.001) and decreased post-hospital care (OR 0.45, 0.32–0.63, p < 0.001).ConclusionUninsured status is independently associated with higher in-hospital mortality and decreased post-hospital care in patients with severe injuries in a nationally representative sample of trauma centres in the United States. Increased in-hospital mortality is likely due to endogenous patient factors while decreased post-hospital care is likely due to economic constraints. Minority race is less of a factor influencing disparate outcomes among the severely injured.     

Morbidity or mortality? Variations in trauma centres in the rescue of older injured patients

IntroductionPrior analysis demonstrates improved survival for older trauma patients (age > 64 years) treated at trauma centres that manage a higher proportion of geriatric patients. We hypothesised that ‘failure to rescue’ (death after a complication during an in-hospital stay) may be responsible for part of this variation. The objective of the study was to determine if trauma centre failure to rescue rates are associated with the proportion of older trauma seen.MethodsWe analysed data from high volume level 1 and 2 trauma centres participating in the National Trauma Data Bank, years 2007–2011. Centres were categorised by the proportion of older trauma patients seen. Logistic regression analyses were used to provide risk-adjusted rates for major complications (MC) and, separately, for mortality following a MC. Models were adjusted for patient demographics, comorbid conditions, mechanism and type of injury, presenting vital signs, injury severity, and multiple facility-level covariates. Risk-adjusted rates were plotted against the proportion of older trauma seen and trends determined.ResultsOf the 396,449 older patients at 293 trauma centres that met inclusion criteria, 30,761 (8%) suffered a MC. No difference was found in the risk-adjusted incidence of MC by proportion of older trauma seen. A MC was associated with 34% of all deaths. Of those that suffered a MC, 7413 (24%) died and 76% were successfully rescued. Centres treating higher proportions of older trauma were more successful at rescuing patients after a MC occurred. Patients seen at centres that treat >50% older trauma were 33% (OR = 0.67, 95% CI 0.47–0.96) less likely to die following a MC than in centres treating a low proportion (10%) of older trauma.ConclusionsCentres more experienced at managing geriatric trauma are more successful at rescuing older patients with serious complications. Processes of care at these centres need to be further examined and used to inform appropriate interventions.     

Trauma centre outcome performance: a comparison of young adults and geriatric patients in an inclusive trauma system

BackgroundElderly trauma patients represent a unique clientele requiring specialised care but they rarely benefit from standardised care strategies within trauma systems. We aimed to evaluate whether trauma centres with lower/higher than expected mortality amongst patients <65 years of age have similar results for geriatric patients. A secondary objective was to compare transfer to level I/II trauma centres across age groups.MethodsThe study was based on data from a Canadian provincial trauma registry (1999–2006). Outcome performance was evaluated with estimates of risk-adjusted 30-day mortality generated for each of the system's 57 adult trauma centres. Agreement in performance results was evaluated with correlation coefficients.ResultsThe study sample comprised 55,283 young adults (3.5% mortality) and 30,960 geriatric patients (8.2% mortality). The two age groups only had one out of six outliers in common. Hospital ranks amongst young adults were not correlated to those assigned amongst geriatric patients (r = 0.01, 95%CI ?0.25;0.27). Correlation was also low for patients with major trauma (r = 0.20, 95%CI ?0.06;0.44). Amongst patients with severe head injuries initially received in a level III/IV centre, 81% of young adults versus 71% of geriatric patients were transferred to a level I/II centre (p < 0.0001).ConclusionsTrauma centres that have low risk-adjusted mortality for young adults do not necessarily do so for geriatric patients. In addition, geriatric patients with severe head injuries are less likely to be treated in neurosurgical trauma centres. Further research is needed to identify determinants of inter-hospital variation in outcome for geriatric trauma patients.     

A modified Kampala trauma score (KTS) effectively predicts mortality in trauma patients

BackgroundMortality prediction in trauma patients has relied upon injury severity scoring tools focused on anatomical injury. This study sought to examine whether an injury severity scoring system which includes physiologic data performs as well as anatomic injury scores in mortality prediction.MethodsUsing data collected from 18 Level I trauma centers and 51 non-trauma center hospitals in the US, anatomy based injury severity scores (ISS), new injury severity scores (NISS) were calculated as were scores based on a modified version of the physiology-based Kampala trauma score (KTS). Because pre-hospital intubation, when required, is standard of care in the US, a modified KTS was calculated excluding respiratory rate. The predictive ability of the modified KTS for mortality was compared with the ISS and NISS using receiver operating characteristic (ROC) curves.ResultsA total of 4716 individuals were eligible for study. Each of the three scores was a statistically significant predictor of mortality. In this sample, the modified KTS significantly outperformed the ISS (AUC = 0.83, 95% CI 0.81–0.84 vs. 0.77, 95% CI 0.76–0.79, respectively) and demonstrated similar predictive ability compared to the NISS (AUC = 0.83, 95% CI 0.81–0.84 vs. 0.82, 95% CI 0.80–0.83, respectively).ConclusionsThe modified KTS may represent a useful tool for assessing trauma mortality risk in real time, as well as in administrative data where physiologic measures are available. Further research is warranted and these findings suggest that the collection of physiologic measures in large databases may improve outcome prediction.     

The effect of Helicopter Emergency Medical Services on trauma patient mortality in the Netherlands

IntroductionObject of this study was to evaluate the effect of the Helicopter Emergency Medical Services (HEMS) on trauma patient mortality and the effect of prehospital time on the association between HEMS and mortality.Materials and methodsTrauma patients admitted to a level 1 trauma centre and treated on-scene by the HEMS and Emergency Medical Services (EMS) between 2003 and 2008 were included (n = 186). A control group treated by EMS only (n = 186) was created by matching on ISS, age and severe traumatic brain injury (TBI). Mortality was compared by calculating odds ratios (OR) and numbers needed to treat (NNT), with adjustment for prehospital coded Revised Trauma Score. The effect of prehospital time mortality was tested by a logistic regression. Analyses were made for patients with and without TBI.ResultsThe OR of early trauma fatality for the HEMS/EMS versus EMS-only groups was 0.8 for patients both with TBI (95% CI 0.4–1.7; NNT: 22) and without TBI (95% CI 0.2–3.3; NNT: 273). The risk of in-hospital mortality was non-significantly higher for patients with TBI in the HEMS/EMS group (OR = 1.3; 95% CI 0.6–2.7; NNT: ?15) compared to the EMS-only group and non-significantly lower for patients without TBI (OR = 0.9; 95% CI 0.3–2.5; NNT: 129). After adjustment for prehospital time, the risk of early trauma fatality for patients with TBI treated by the HEMS decreased (OR = 0.6; 95% CI 0.3–1.6). The risk of in-hospital mortality for these patients decreased from 1.3 to 0.8 (95% CI 0.4–2.0). The effect of the HEMS on patients without TBI did not change after adjustment for prehospital time.DiscussionHEMS treatment is associated with a non-significantly higher risk of in-hospital mortality for patients with TBI and a non-significantly lower risk for patients without TBI. This increased risk of mortality in TBI patients is attributable to the increased prehospital time. These results indicate that HEMS does not have a positive impact on survival.     

Extracorporeal life support is safe in trauma patients

IntroductionThe role of extracorporeal life support (ECLS) in the critically ill trauma patient is poorly defined, possibly leading to the underutilization of this lifesaving therapy in this population. This study examined survival rates and risk factors for death in trauma patients who received ECLS.MethodsData from the National Trauma Data Bank was retrospectively reviewed to identify trauma patients who received ECLS from January 2012 to December 2014. Clinical outcomes and risk factors for death were examined in these patients.ResultsEighty patients were identified and included in the final analysis. Overall survival to hospital discharge was 64%. Survivors and non-survivors were similar in regard to age, gender, weight, and injury mechanism. Non-survivors had greater median injury severity scores (ISS) (29 non-survivors vs. 24 survivors, p = 0.018) and had a shorter median total hospital length of stay (8 days non-survivors vs. 32 days survivors, p < 0.001). Analysis of specific anatomic locations of traumatic injury, including serious head/neck, thoracic, and abdominal injuries, revealed no impact on patient survival. Multivariable logistic regression analysis identified increasing age and ISS as significant risk factors for mortality; whereas treatment at facilities that performed multiple ECLS runs over the study period was associated with improved survival.ConclusionsExtracorporeal life support appears to be an effective treatment option in trauma patients with severe cardiopulmonary failure. Survival in trauma patients receiving ECLS is similar to that observed in the general ECLS population and this may represent an underutilized therapy in this population.     

Prediction of intra-hospital mortality after severe trauma: which pre-hospital score is the most accurate?

PurposeComputing trauma scores in the field allows immediate severity assessment for appropriate triage. Two pre-hospital scores can be useful in this context: the Triage-Revised Trauma Score (T-RTS) and the Mechanism, Glasgow, Age and arterial Pressure (MGAP) score. The Trauma Revised Injury Severity Score (TRISS), not applicable in the pre-hospital setting, is the reference score to predict in-hospital mortality after severe trauma. The aim of this study was to compare T-RTS, MGAP and TRISS in a cohort of consecutive patients admitted in the Trauma system of the Northern French Alps(TRENAU).Materials and methodsFrom 2009 to 2011, 3260 patients with suspected severe trauma according to the Vittel criteria were included in the TRENAU registry. All data necessary to compute T-RTS, MGAP and TRISS were collected in patients admitted to one level-I, two level-II and ten level-III trauma centers. The primary endpoint was death from any cause during hospital stay. Discriminative power of each score to predict mortality was measured using receiver operating curve (ROC) analysis. To test the relevancy of each score for triage, we also tested their sensitivity at usual cut-offs. We expected a sensitivity higher than 95% to limit undertriage.ResultsThe TRISS score showed the highest area under the ROC curve (0.95 [CI 95% 0.94–0.97], p < 0.01). Pre-hospital MGAP score had significantly higher AUC compared to T-RTS (0.93 [CI 95% 0.91–0.95] vs 0.86 [CI 95% 0.83–0.89], respectively, p < 0.01). MGAP score < 23 had a sensitivity of 88% to detect mortality. Sensitivities of T-RTS < 12 and TRISS < 0.91 were 79% and 87%, respectively.Discussion/conclusionPre-hospital calculation of the MGAP score appeared superior to T-RTS score in predicting intra-hospital mortality in a cohort of trauma patients. Although TRISS had the highest AUC, this score can only be available after hospital admission. These findings suggest that the MGAP score could be of interest in the pre-hospital setting to assess patients’ severity. However, its lack of sensitivity indicates that MGAP should not replace the decision scheme to direct the most severe patients to level-I trauma center.     

Rising mortality in patients with combined burn and trauma

Combined trauma in the burn patient has been previously shown to have higher mortality. With improved critical care and multidisciplinary approach, we hypothesized the risk of mortality in combined burn and trauma has decreased. A retrospective analysis of trauma, burn and combined burn-trauma patients in the National Trauma Data Bank was performed comparing years 2007–2015 to years 1994–2002. The impact of burn injuries on mortality in patients with minor trauma has decreased (OR 2.45, CI 2.26–2.66, p < 0.001 compared to OR 4.04, CI 4.51–4.66, p < 0.001) in years 2007–2015 while the impact of burn injuries on mortality in patients with severe trauma has increased (OR 1.37, CI 1.29–1.47, p < 0.001 compared to OR 1.26, CI 1.05–1.51, p < 0.001). When controlling for known risk factors of mortality in burn and trauma, the contribution of the severity of trauma on mortality in combined burn-trauma patients with total body surface area ≥20% is negligible. In contrast, an increase in percentage of total body surface area burned is associated with a step-wise increase in mortality for all combined burn-trauma patients. However, the largest impact is seen in patients with minor trauma. This population represents a unique overlap of patients where future collaborative research can help identify best practices and improve outcomes.     

The impact of the Major Trauma Network: will trauma units continue to treat complex foot and ankle injuries?

IntroductionApril 1st 2012 saw the introduction of National Trauma Networks in England. The aim to optimise the management of major trauma. Patients with an ISS ≥ 16 would be transferred to the regional Major Trauma Centre (level 1). Our premise was that trauma units (level 2) would no longer manage complex foot and ankle injuries thereby obviating the need for a foot and ankle specialist service.MethodsRetrospective analysis of the epidemiology of foot and ankle injuries, using the Gloucestershire trauma database, from a trauma unit with a population of 750,000. Rates of open fractures, complex foot and ankle injuries and requirement for stabilisation with external fixation were reviewed before and after the introduction of the regional Trauma Network. Secondly, using the Trauma Audit & Research Network (TARN) database, all foot and ankle injuries triaged to the regional Major Trauma Centre (MTC) were reviewed.ResultsIncidence of open foot and ankle injuries was 2.9 per 100,000 per year. There were 5.1% open injuries before the network and 3.2% after (p > 0.05). Frequency of complex foot and ankle injuries was 4.2% before and 7.5% after the network commenced, showing no significant change. There was no statistically significant change in the numbers of patients with complex foot and ankle injuries treated by application of external fixators. Analysis of TARN data revealed that only 18% of patients with foot and ankle injuries taken to the MTC had an ISS ≥ 16. The majority of these patients were identified as requiring plastic surgical intervention for open fractures (69%) or were polytrauma patients (43%). Only 4.5% of patients had isolated, closed foot and ankle injuries.ConclusionWe found that at the trauma unit there was no decrease in the numbers of complex foot and ankle injuries, open fractures, or the applications of external fixators, following the introduction of the Trauma Network. These patients will continue to attend trauma units as they usually have an ISS < 16. Our findings suggest that there is still a need for foot and ankle specialists at trauma units, in order to manage patients with complex foot and ankle injuries.     

Trauma morning report is the ideal environment to teach and evaluate resident communication and sign-outs in the 80 hour work week

BackgroundThe 80 h work week has raised concerns that complications may increase due to multiple sign-outs or poor communication. Trauma Surgery manages complex trauma and acute care surgical patients with rapidly changing physiology, clinical demands and a large volume of data that must be communicated to render safe, effective patient care. Trauma Morning Report format may offer the ideal situation to study and teach sign-outs and resident communication.Materials and methodsSurgery Residents were assessed on a 1–5 scale for their ability to communicate to their fellow residents. This consisted of 10 critical points of the presentation, treatment and workup from the previous night’s trauma admissions. Scores were grouped into three areas. Each area was scored out of 15. Area 1 consisted of Initial patient presentation. Area 2 consisted of events in the trauma bay. Area 3 assessed clarity of language and ability to communicate to their fellow residents. The residents were assessed for inclusion of pertinent positive and negative findings, as well as overall clarity of communication. In phase 1, residents were unaware of the evaluation process. Phase 2 followed a series of resident education session about effective communication, sign-out techniques and delineation of evaluation criteria. Phase 3 was a resident-blinded phase which evaluated the sustainability of the improvements in resident communication.Results50 patient presentations in phase 1, 200 in phase 2, and 50 presentations in phase 3 were evaluated. Comparisons were made between the Phase 1 and Phase 2 evaluations. Area 1 (initial events) improved from 6.18 to 12.4 out of 15 (p < 0.0001). Area 2 (events in the trauma bay) improved from 9.78 to 16.53 (p < 0.0077). Area 3 (communication and language) improved from 8.36 to 12.22 out of 15 (P < 0.001). Phase 2 to Phase 3 evaluations were similar, showing no deterioration of skills.ConclusionsTrauma Surgery manages complex surgical patients, with rapidly changing physiologic and clinical demands. Trauma Morning Report, with diverse attendance including surgical attendings and residents in various training years, is the ideal venue for real-time teaching and evaluation of sign-outs and reinforcing good communication skills in residents.     

Sudden survival improvement in critical neurotrauma: An exploratory analysis using a stratified statistical process control technique

BackgroundOutcome after trauma depends on patient characteristics, quality of care, and random events. The TRISS model predicts probability of survival (Ps) adjusted for Injury Severity Score (ISS), Revised Trauma Score (RTS), mechanism of injury, and age. Quality of care is often evaluated by calculating the number of “excess” survivors, year by year. In contrast, the Variable Life-Adjusted Display (VLAD) technique allows rapid detection of altered survival. VLAD adjusts each death or survival by the patient's risk status and graphically displays accumulated number of unexpected survivors over time. We evaluated outcome changes and their time relation to trauma service improvements.MethodsObservational, retrospective study of the total 2001–2011 trauma population from a Level I trauma centre. Outcome was 30-day survival. Ps was calculated with the TRISS model, 2005 coefficients. VLAD graphs were created for the entire population and for subpopulations stratified by ISS level, ISS body region (Head/Neck, Face, Chest, Abdomen/Pelvic contents, Extremities/Pelvic girdle, External), and maximum Abbreviated Injury Scale (maxAIS) score in each region. Piecewise linear regression identified VLAD graph breakpoints.Results12,191 consecutive trauma patients (median age 35 years, 72% males, 91% blunt injury, 41% ISS ≥ 16) formed the dataset. Their VLAD graph indicated performance equal to TRISS predicted survival until a sudden improvement in late 2004. From then survival remained improved but unchanged through 2011. Total number of excess survivors was 141. Inspection of subgroup VLAD graphs showed that the increased survival mainly occurred in patients having at least one Head/Neck AIS 5 injury. The effect was present in both isolated and multitraumatised maxAIS 5 Head/Neck trauma. The remaining trauma population showed unchanged survival, superior to TRISS predicted, throughout the study period.Important general and neurotrauma-targeted improvements in our trauma service could underlie our findings: A formalised trauma service, damage control resuscitation protocols, structured training, increased helicopter transfer capacity, consultant-based neurosurgical assessment, a doubling of emergency neurosurgical procedures, and improved neurointensive care.ConclusionsStratified VLAD enables continuous, high-resolution system analysis. We encourage trauma centres to explore their data and to monitor future system changes.     

Variation in patterns of hospitalization and associated resource use among children with spinal cord injury in the U.S.

IntroductionTrauma is a leading cause of mortality and morbidity among children in the U.S. There is paucity of data on the triage of children with spinal cord injury (SCI) to definitive trauma care, and it is unknown if clinical outcomes and resource utilization for children hospitalized with SCI vary according to the settings where trauma care is provided. The study was conducted to describe recent patterns of emergency department (ED) evaluation for paediatric SCI in the U.S., and to characterize outcomes and resource use for children hospitalized at non-trauma centres versus trauma centres.Materials and methodsSecondary analysis of a national database on injured children 0–20 years evaluated at U.S. EDs and either hospitalized or released, in 2009–2012. In-hospital mortality, duration of stay, and overall charges, were compared according to trauma centre status of the treating hospital.ResultsOf an estimated 67 million annual paediatric visits to the ED for trauma evaluation nationally in 2009–2012, 2317 had SCI. Majority (87%) of children evaluated for SCI were under 6 years of age, and boys comprised 73% of the visits. Injuries were caused mainly by motor vehicle accidents, falls, non-transport-related accidents, and firearms. The South census region had the most ED visits and hospitalizations. Majority (92%) of the most severely injured was evaluated at trauma centres, and more visits to trauma centres (81% vs. 18%, p = 0.022) resulted in hospitalization. Among an estimated 1570 hospitalizations of children with SCI from the ED nationally, children at trauma centres were more likely to have major injuries (67% vs. 44%, p = 0.001), similar mortality, longer average hospital stay, and higher charges, compared with children hospitalized at non-trauma centres.ConclusionSignificant demographic and geographical variation exists in national patterns of hospital care for paediatric SCI. Higher severity of patient injury was associated with concomitantly higher hospital resource use at trauma centres.     

Socioeconomic correlates of trauma: An analysis of emergency ward patients in Yaoundé, Cameroon

IntroductionInjury is a significant and increasingly common cause of morbidity and mortality in sub-Saharan Africa; however, the social and economic factors underlying these trends are not well understood. We evaluated the relationship between socioeconomic status (SES) and trauma outcomes using a prospective registry of patients presenting to the largest trauma hospital in Yaoundé, Cameroon.MethodsTrauma patients (n = 2855) presenting to the emergency ward at Central Hospital, Yaoundé between April 15 and October 15, 2009 were surveyed regarding demographic and socioeconomic background, nature and severity of injuries, treatment, and disposition. A wealth score was estimated for each patient, corresponding to an SES index constructed using principle components analysis of the urban Cameroonian Demographic and Health Survey. Logistic regression was used to evaluate the effects of SES on care-seeking behaviour, injury severity, and treatment outcome.Main outcome measures: SES wealth score, care-seeking prior to visiting hospital, injury severity, treatment outcome.ResultsPatients aged 1–89 presented with road traffic injuries (59.83%), falls (7.76%), and penetrating trauma (6.16%), and had higher SES than the broader urban Cameroonian population. Within the Yaoundé sample, being in the lowest SES quintile was associated with an increased likelihood of having sought care elsewhere before presenting to the hospital (aOR = 3.28, p < 0.001), after controlling for background and injury characteristics. Patients in the lowest SES quintile were also more likely to present with moderate/severe injuries (aOR = 4.93, p < 0.001), and were more likely to be transferred to the operating room.ConclusionsPatients presenting to this trauma centre were wealthier than the broader community, suggesting the possibility of barriers to accessing care. Poorer patients were more likely to have severe injuries and more likely to need surgery, but were less likely to seek care from a major trauma centre immediately. Substantial differences in SES between the sample visiting the hospital and the broader community suggest a need for community-based sampling approaches in future trauma research.     

Hepatic dysfunction: A common occurrence in severely injured patients

BackgroundHepatic dysfunction (HD) is a common finding in critically ill patients. The underlying pathophysiological process is one of either cholestasis or hypoxic liver injury (HLI). Using serum bilirubin, our study aimed to determine the incidence of HD in a critically ill trauma population, identify risk factors and analyse the impact on outcomes.MethodsA retrospective observational study was performed on all patients admitted to the Level 1 Trauma Unit ICU at Inkosi Albert Luthuli Central Hospital in Durban, South Africa (IALCH) from 01/01/2012 until 31/12/2012. HD was defined as a total bilirubin greater than 34.2 μmol/l (2 mg/dL). Additional demographic, physiological, biochemical, and pharmaceutical risk factors for hepatic dysfunction were identified and recorded.ResultsTwo hundred and twenty five patients were included in the study of whom 48 (21.3%) developed HD. An increased duration of ventilation (median 15 days [inter-quartile range 6–19] vs 6 days [IQR 3–11] p < 0.001), prolonged length of stay (median 19 days [IQR 8.5–31] vs 7 days [IQR 3–13] p < 0.001), and higher mortality rate (31.3% vs. 14.7% p = 0.01) were all significantly associated with HD. Shock on admission was twice as common in patients developing HD (p < 0.001). The only drugs associated with HD were piperacillin-tazobactam (p < 0.001) and enalapril (p = 0.04). On multivariable analysis however, HD was not associated with mortality.ConclusionHD was common in our study population, and was associated with other organ dysfunction, increased mortality and length of stay.     

Polytrauma patients in the Netherlands and the USA: A bi-institutional comparison of processes and outcomes of care

BackgroundModern trauma systems differ worldwide, possibly leading to disparities in outcomes. We aim to compare characteristics and outcomes of blunt polytrauma patients admitted to two Level 1 Trauma Centers in the US (USTC) and the Netherlands (NTC).MethodsFor this retrospective study the records of 1367 adult blunt trauma patients with an Injury Severity Score (ISS) ≥ 16 admitted between July 1, 2011 and December 31, 2013 (640 from NTC, 727 from USTC) were analysed.ResultsThe USTC group had a higher Charlson Comorbidity Index (mean [standard deviation] 1.15 [2.2] vs. 1.73 [2.8], p < 0.0001) and Injury Severity Score (median [interquartile range, IQR] 25 [17–29] vs. 21 [17–26], p < 0.0001). The in-hospital mortality was similar in both centers (11% in USTC vs. 10% NTC), also after correction for baseline differences in patient population in a multivariable analysis (adjusted odds ratio 0.95, 95% confidence interval 0.61–1.48, p = 0.83). USTC patients had a longer Intensive Care Unit stay (median [IQR] 4 [2–11] vs. 2 [2–7] days, p = 0.006) but had a shorter hospital stay (median [IQR] 6 [3–13] vs. 8 [4–16] days, p < 0.0001). USTC patients were discharged more often to a rehabilitation center (47% vs 10%) and less often to home (46% vs. 66%, p < 0.0001), and had a higher readmission rate (8% vs. 4%, p = 0.01).ConclusionAlthough several outcome parameters differ in two urban area trauma centers in the USA and the Netherlands, the quality of care for trauma patients, measured as survival, is equal. Other outcomes varied between both trauma centers, suggesting that differences in local policies and processes do influence the care system, but not so much the quality of care as reflected by survival.     

The impact of BMI on polytrauma outcome

BackgroundVarying results have been reported concerning the effect of body mass index (BMI) on polytrauma outcome. Although most studies focus on obesity and its associated preexisting medical diseases as a predictor for increased mortality rates, there is evidence that polytrauma patients with underweight also face an inferior outcome.MethodsRecords of 5766 trauma patients (minimum 18 years of age, Injury Severity Score ≥ 16, treated from 2004 to 2008) documented in the Trauma Registry of the German Society for Trauma Surgery were subclassified into 4 BMI groups and analysed to assess the impact of BMI on polytrauma outcome.ResultsUnderweight (BMI Group I) as well as obesity (BMI Group IV) in polytraumatized patients are associated with significantly increased mortality by multivariate logistic regression analysis with hospital mortality as the target variable (adjusted odds ratio for BMI Group I, 2.1 (95% CI 1.2–3.8, p = 0.015); for BMI Group IV, 1.6 (95% CI 1.1–2.3, p = 0.009)). Simple overweight (BMI Group III) does not qualify as a predictor for increased mortality (odds ratio 1.0; 95% CI 0.8–1.3).ConclusionsThere is a significant correlation between obesity, underweight, and increased mortality in polytraumatized patients. Efforts to promote optimal body weight may reduce not only the risk of chronic diseases but also the risk of polytrauma mortality amongst obese and underweight individuals.     

Retrievable inferior vena cava filters in geriatric trauma: Is there an age bias?

BackgroundTrauma patients are at increased risk for developing venous thromboembolic (VTE) disease. The EAST (Eastern Association for the Surgery of Trauma) practice management guidelines identified risk factors for VTE, as well as indications for prophylactic inferior vena cava filters (IVCF). In a 2009 study, our institution found a 26% retrieval rate for IVCF. Lack of retrieval was most consistently due to lack of follow-up. Our study is a follow-up analysis for retrieval rate of IVCF, since the formation of a geriatric trauma service. We anticipated that geriatric trauma patients would have a lower rate of IVCF retrieval compared to the general trauma patient.MethodsOur study population consisted of trauma patients admitted from January 2008 to August 2013, with documented VTE or high risk for VTE with contraindication to anticoagulation. Inclusion criteria: IVCF placed in trauma patients. Exclusion criteria: permanent filters, retrievable filters placed permanently, non-trauma patients, superior vena cava filters and patients who died before discharge.ResultsDuring the study period, 160 trauma patients had an IVCF placed, of which 147 survived and were discharged. Of those patients, 66% (97/147) were planned for retrieval. Overall, the retrieval rate was 34% (33/97). Following age categorization, rates were 47% (30/64) and 9% (3/33) for those < 65 and >/ = 65 years old, respectively. Applying Fisher’s Exact Test to a crosstab of planned retrieval by age category yielded a statistically significant difference, p < 0.0005 at alpha = 0.05. In the geriatric population with IVCFs not retrieved, 23% (7/30) died and 67% (20/30) were lost to follow-up.ConclusionIVCF plays a critical role in the management of trauma patients with VTE, particularly the geriatric population. Since our 2009 study, we have improved nearly ten percentage points (26% to 34%); however, we exposed an age bias with retrieval rate being lower in patients >/ = 65 compared to those < 65 (9% vs. 47%).     

Is pain really undertreated? Challenges of addressing pain in trauma patients during prehospital transport and trauma resuscitation

BackgroundPrior research has documented the inadequacy of pain management for trauma patients in the emergency department (ED), with rates of pain assessment and opioid administration averaging about 50%. Such rates, however, may be misleading and do not adequately capture the complexity of pain management practices in a trauma population. The goal of the study was to determine if pain was undertreated at the study hospital or if patient acuity explained the timing and occurrence of pain treatment in the prehospital setting and the ED.MethodsA retrospective study was performed at a Level 1 adult trauma centre in the Midwest. The trauma registry was used to identify patients who received a trauma activation during the study period (June–November 2012; N = 313). Using the first set of patient vitals and ISS, patients were grouped into three categories: physiologically stable with low injury severity (n = 132); physiologically stable with moderate to severe injury (n = 122); and physiologically unstable with severe injury (n = 56). Differences were assessed with Kruskal–Wallis and chi-square tests.ResultsPatients who were physiologically unstable were the least likely to receive a standardised pain assessment and the least likely to receive an opioid in the ED. Patients who were physiologically stable at entry to the ED but sustained a severe injury were the most likely to receive an opioid. Time to first pain assessment and time to first opioid did not differ by patient acuity.ConclusionsResults confirm that patient acuity greatly affects the ability to effectively and appropriately manage pain in the initial hours after injury. This study contributes to the literature by noting areas for improvement but also in explaining why delaying pain treatment may be appropriate in certain patient populations.     

Mortality,functional and return to work outcomes of major trauma patients injured from deliberate self-harm

BackgroundSelf-harm and intentional injuries represent a significant public health concern. People who survive serious injury from self-harm can experience poor outcomes that negatively impact on their daily life. The aim of this study was to investigate a cohort of major trauma patients hospitalised for self-harm in Victoria, and to identify risk factors for longer term mortality, functional recovery and return to work.Method482 adult major trauma patients who were injured due to self-harm and survived to hospital discharge, and were captured by the population-based Victorian State Trauma Registry (VSTR), were included. For those with a date of injury from January 1, 2007 to December 31, 2013, demographics and injury event data, Glasgow Outcome Scale Extended (GOS-E) and return to work (RTW) outcomes at 6, 12 and 24 months post-injury were extracted from the registry. Post-discharge mortality was identified through the Victorian Registry of Births, Deaths and Marriages (BDM). Multivariable logistic regression was used to determine predictors of the GOS-E and RTW and survival analysis was used to identify predictors of mortality.ResultsA total of 37 (7.7%) deaths occurred post-discharge. There were no clear predictors of all-cause mortality. Overall, 36% of patients reported making a good recovery at 24 months. Older age (p = 0.01), transport-related methods of self-harm (p = 0.02), higher Injury Severity Score (p < 0.001) and having a Charlson Comorbidity Index weighting of one or more (p = 0.02) were predictive of poorer functional recovery. Of patients who were working or studying prior to injury, 54% reported returning to work by 24 months post-injury. Higher Injury Severity Score was an important predictor of not returning to work (p = 0.002).ConclusionThe vast majority of major trauma patients who self-harmed and survived to hospital discharge were alive at two years post-injury, yet only half of this cohort returned to work and just over a third of patients experienced a good recovery.